Faculty Student Association (FSA) Payment Form DATE Prepared

FSA Office Use Only
Faculty Student Association (FSA)
Payment Form
Check #: ___________________
Check Date: ________________
Typed Forms Only: Submit completed form to Business Office: mail to MSC1219 or hand deliver to Student Center, Room 2-09. An advance copy by fax or scan/
eMail can initiate processing, but check will not be disbursed until fully signed hard copy is received. General form Instructions link
SAF instructions link
DATE Prepared: _____________________________________
(Account Type:check one)
FSA Direct Operation
FSA Trust and Agency (T&A)
FSA Student Activity Fund (SAF)
ORGANIZATION, DEPT.
or STUDENT COUNCIL NAME:_____________________________________________________________________________
ACCOUNT NUMBER
TO BE CHARGED:
_____________________________
Account Title/Club Name: _______________________________
TOTAL Check Amount:_____________ CHECK PAYABLE TO (Payee Name):________________________________________
check one:
1) Attach Original Invoice(s)
2) Attach Any/All Receipt(s) for Goods or Services
___ PICK UP CHECK AT FSA OFFICE or ___mail check to:
Address: ____________________________________________
____________________________________________________
City, State, Zip: _______________________________________
PURPOSE: Must be a specific and clear description of this payment/ transaction. Attach any and all applicable supporting
documentation, such as letters of explanation/ justification, invoices, meeting minutes, contract, etc.. Note: Advances, when
approved, may be issued with receipts to be submitted. Failure to submit receipts will result in account being frozen.
Authorized Signature: _________________________________ ORGANIZATION Title: ________________________________
Print Name: __________________________________
WHEN JOINT SIGNATURE IS REQUIRED BY ORGANIZATION:
Authorized Signature: ________________________________ ORGANIZATION Title: _________________________________
Print Name:___________________________________
This section is for FSA OFFICE USE ONLY:
ACCOUNT NUMBER
ACCOUNT TITLE
DEBIT
Check Received By:_____________________________________ Date:__________________________
CREDIT
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